Facility E&M Level Guidelines question on Prep for Diagnostic Tests

Pvdcoder

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I wanted to get your opinions on choosing a level when the doctor orders a test whether it be an x-ray, ultrasound or ct/mri/nuc/vasc test etc. If he/she orders the test and it is then cancelled or the patient never had it done are we still to consider it as prep for and apply the level 3 or 4 if not higher? I always assumed it was ordered and completed and you can apply the level but am now told even if they cancelled the test we should give the level as if it was done. Can someone please let me know their views on this? Thank you so much in advance.
 

LPou1003

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I was taught that you give the provider credit for any work up that he takes it into consideration when treating the patient. Remember that it needs to be documented on the note to be given credit. Also, the test ordered doesn't need to be completed that day to be given credit.

I hope this helps

Leslie
 

Pvdcoder

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I was taught that you give the provider credit for any work up that he takes it into consideration when treating the patient. Remember that it needs to be documented on the note to be given credit. Also, the test ordered doesn't need to be completed that day to be given credit.

I hope this helps

Leslie

Thank you so much, that definitely does help and makes a lot of sense. I appreciate your feedback!
 

CodingKing

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Facility and professional do not follow the same leveling guidelines so i'm not sure the answer is correct. Ordering of tests regardless as to whether they are done are not, may affect MDM but Facility leveling is not based on MDM.
 
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bdette810

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facility e/m

I think it is facility specific. it is based on what your facility policy states on how count certain situations such as cancelled ancillary tests.
 
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